HomeMy Public PortalAbout10538 DANBURY ST_Plumbing_6/25/1993_fixtures WORKER'S
haveCOMPENSATIONcertificate
DECLARATION 76A667 DPW 9189 APPLICATION FOR PLUMBING PERMIT 11
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I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified
copy thereof(Sec.3800 Lab.C.)
COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV.
Policy No. Company
❑ Certified copy is hereby furnished.
FOR APPLICANT TO FILL (PRINT OR TYPE) BUILDING day 3� D9,Jr��� .5T
❑ Certified copy is fled with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM Of FEE
LOCALITY 'TEMPLE GIT -
Date Applicant 1Z WATER CLOSET �In 0a NEAREST nz� �, ^ ��]] ,{ L
CERTIFICATE OF EXEMPTION FROM-WORKERS' BATH TUB CROSS ST. /,fJ L M/JL /S"✓G
COMPENSATION INSURANCE ASSESSOR
(This section need not be completed If the work involved by the / SHOWER I MAP BOOK I PAGE PARCEL
permit is for one hundred dollars($100)or less.) q LAVATORY k' OWNER ✓7 a sA1L/rt1,1/� V d�
I certify that in the performance of the work for which this permit Z p.�� D IST/•• A IG
is issued, I shall not employ an MAIL A
p y y person in any manner so as [0 1 SINK ,K1 �),� �O ADDRESS 5,6MC VE
become subject to the Workers' Compensation Laws.
DISWASHER CITY T . .•JJ'7['D779
—
Date Applicant CLOTHES WASHER GG/ // //
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor Code, you must forthwith comply with such - ADDRESS
provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY TEL.NO. }
I hereby affirm that I am licensed under provisions of Chapter 9 I WATER HEATER DO d
(commencing with Section 7000) of Division 3 of the Business and STATE LIC. 0
Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. CLASS 0
OUTLETS OVER j DISTRICT NO. L PROCESSED BY Q
5 PER SYSTEM O L L 0
License Number - Lia Class O I_
FINAL
DATE 17 VALIDATIONCL
W
Contractor Date r .a (D
EJ FINAL I am exempt antler Sec. ay ='13,:.
B.&P.C.for this reason 1 ITEMS
Plan check fee
Signature
Date: PLUMBING PERMIT ISSUING FEE$ 2E ® - TOTAL AL 130 w 65
I. L�
(' ,Q
❑ TOTAL FEE CHEU, 1 J
Plan check applicant _ t.HANIGE 'UI}
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Name OOT'
I hereby affirm that I am exempt from the Contractor's License Law 0000—OW1 6/253/5'7
for the following reason (Section 7031.5, Business and Professions Address
CodT'e) City Tel. No. 134617 1 AM 2:57
I, as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec. 3097,
Civ.C.)
Lender's Name
Lender's Address
1 certify that I have read this application and stale that the above
information is correct. I agree to comply with all County ordinances
and State laws regulaL Plumbing, and hereby authorize
representatives of this �)to enter upon the above-mentioned
property for inspectio l es. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Per RRrb Date